PRO-ACTIVE: Prophylactic Swallow Intervention for Patients Receiving Radiotherapy for Head and Neck Cancer

Dysphagia Clinical Trial

— PRO-ACTIVE  

Official title:

PRO-ACTIVE: Comparing The Effectiveness of Prophylactic Swallow Intervention for Patients Receiving Radiotherapy for Head and Neck Cancer

Clinical Trial Details — Status: Active, not recruiting

Administrative data

• NCT number: NCT03455608
• Other study ID #: CTO1363
• Status: Active, not recruiting
• Phase: N/A
• Start date: September 27, 2018
• Est. completion date: December 2024

Study information

• Verified date: October 2023
• Source: University Health Network, Toronto
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

Dysphagia (difficulty swallowing) is a common and potentially life-threatening toxicity of radiotherapy (RT) for patients with head and neck cancer (HNC). HNC survivors have a 20-24 percent lifetime risk of pneumonia after RT, which is associated with a 42 percent excess risk of death in survivorship. Moreover, dysphagia predisposes individuals to malnutrition, and at least half of HNC patients require feeding tubes during RT.

Patients are commonly referred for swallowing therapy with a speech pathologist. Some patients receive early intervention, before a swallowing problem begins-PRO-ACTIVE therapy. Other patients are monitored and prescribed dysphagia interventions only if and when a swallowing problem occurs-RE-ACTIVE therapy. Thus, REACTIVE therapy aims to reverse an already impaired swallowing ability, whereas PRO-ACTIVE therapy aims to prevent or reduce severity of dysphagia. These two broad categories of therapy represent the most common types of intervention offered to HNC patients across North America. Although there is single-institution evidence to support each practice, it is yet unknown which is most effective.

To address this gap, the primary aim of this international, multi-site 3-arm pragmatic randomized clinical trial is to compare the effectiveness of PRO-ACTIVE (high and low intensity) versus RE-ACTIVE swallowing therapy among 952 patients with HNC planning to undergo RT, using duration of feeding tube dependence after RT as the primary outcome. Our secondary aim proposes to compare the relative benefit or harm of these swallowing interventions on secondary outcomes considered relevant to our stakeholder partners.

Description:

Swallowing therapy is commonly provided as a behavioral treatment to lessen the risk or severity of dysphagia in head and neck cancer (HNC) patients; however, best practice is not established. This multi-site, international randomized clinical trial (RCT) will compare the effectiveness of PRO-ACTIVE (high and low intensity) versus RE-ACTIVE swallowing interventions in 952 HNC patients undergoing radiotherapy (RT). The 3 study arms represent alternate timing and intensity of swallowing therapy delivered by a speech language pathologist: 1) RE-ACTIVE, 2) PRO-ACTIVE EAT, and 3) PRO-ACTIVE EAT + EXERCISE.

The primary aim of the PRO-ACTIVE trial is to compare the effectiveness of PRO-ACTIVE versus RE-ACTIVE swallowing interventions among patients with HNC planned to undergo RT. We hypothesize that the combined PRO-ACTIVE therapies are more effective than RE-ACTIVE therapy; and, if so, that more intensive PRO-ACTIVE (EAT + EXERCISE) is superior to less intensive PRO-ACTIVE (EAT). Effectiveness will be measured based on reduced duration of feeding tube dependency as the primary endpoint, an outcome valued equally by patients, caregivers and clinicians.

The secondary aim of the PRO-ACTIVE trial is to compare the relative benefit or harm of swallowing therapy arms on secondary outcomes including videofluoroscopic swallowing evaluations, functional status measures, health status measures, and patient-reported outcomes.

Recruitment information / eligibility

• Status: Active, not recruiting
• Enrollment: 952
• Est. completion date: December 2024
• Est. primary completion date: December 2024
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years and older

Eligibility

Inclusion Criteria:

• Adults = 18 years of age diagnosed with head and neck malignancy;

• RT treatment planned for curative intent;

• Dispositioned to receive external beam radiotherapy dose =60 gray to bilateral fields at participating institution;

• Sufficient fluency in written English, French, Spanish or Simplified Chinese to be able to complete the study patient reported outcome questionnaires

Exclusion Criteria:

• Distant metastasis at enrollment; or

• Prior or planned total laryngectomy; or

• Moderate/severe dysphagia at enrollment per baseline videofluoroscopy DIGEST grade =2 (as graded per central laboratory review)

• Previously seen by speech language pathologist for swallowing therapy for the current head and neck cancer

• Diagnosis of second primary non-head and neck cancers in the thorax or the central nervous system at enrollment

• Head and neck radiotherapy for thyroid or cutaneous/skin primary tumors, regardless of neck fields

Related Conditions & MeSH terms

• Deglutition Disorders
• Dysphagia
• Head and Neck Neoplasms

Intervention

Behavioral:
• RE-ACTIVE
Reactive intervention started promptly if/when dysphagia is identified
• PRO-ACTIVE EAT
Early low intensity proactive intervention started before RT commences
• PRO-ACTIVE EAT + EXERCISE
Early high intensity proactive intervention started before RT commences

Locations

Country	Name	City	State
Canada	London Health Sciences Centre	London	Ontario
Canada	Jewish General Hospital	Montréal	Quebec
Canada	University Health Network	Toronto	Ontario
United States	Greater Baltimore Medical Center	Baltimore	Maryland
United States	Boston University Medical Center	Boston	Massachusetts
United States	University of Cincinnati	Cincinnati	Ohio
United States	Cleveland Clinic	Cleveland	Ohio
United States	Henry Ford Health System	Detroit	Michigan
United States	University of Texas MD Anderson Cancer Center	Houston	Texas
United States	University of Wisconsin Hospitals and Clinics	Madison	Wisconsin
United States	University of Miami	Miami	Florida
United States	Memorial Sloan Kettering Cancer Center	New York	New York
United States	Orlando Health	Orlando	Florida

Sponsors (5)

Lead Sponsor	Collaborator
University Health Network, Toronto	Applied Health Research Centre, M.D. Anderson Cancer Center, Patient-Centered Outcomes Research Institute, Qualitative Health Research Consultants, LLC

Countries where clinical trial is conducted

United States,  Canada, 

References & Publications (30)

Ang KK, Harris J, Wheeler R, Weber R, Rosenthal DI, Nguyen-Tan PF, Westra WH, Chung CH, Jordan RC, Lu C, Kim H, Axelrod R, Silverman CC, Redmond KP, Gillison ML. Human papillomavirus and survival of patients with oropharyngeal cancer. N Engl J Med. 2010 Jul 1;363(1):24-35. doi: 10.1056/NEJMoa0912217. Epub 2010 Jun 7. — View Citation

Canadian Cancer Society's Advisory Committee on Cancer Statistics. Canadian cancer statistics 2016. 2016; http://www.cancer.ca/en/cancer-information/cancer-101/canadian-cancer-statistics-publication/?region=on. Accessed December 12, 2016.

Carroll WR, Locher JL, Canon CL, Bohannon IA, McColloch NL, Magnuson JS. Pretreatment swallowing exercises improve swallow function after chemoradiation. Laryngoscope. 2008 Jan;118(1):39-43. doi: 10.1097/MLG.0b013e31815659b0. — View Citation

Chaturvedi AK, Engels EA, Pfeiffer RM, Hernandez BY, Xiao W, Kim E, Jiang B, Goodman MT, Sibug-Saber M, Cozen W, Liu L, Lynch CF, Wentzensen N, Jordan RC, Altekruse S, Anderson WF, Rosenberg PS, Gillison ML. Human papillomavirus and rising oropharyngeal cancer incidence in the United States. J Clin Oncol. 2011 Nov 10;29(32):4294-301. doi: 10.1200/JCO.2011.36.4596. Epub 2011 Oct 3. — View Citation

Chen AY, Frankowski R, Bishop-Leone J, Hebert T, Leyk S, Lewin J, Goepfert H. The development and validation of a dysphagia-specific quality-of-life questionnaire for patients with head and neck cancer: the M. D. Anderson dysphagia inventory. Arch Otolaryngol Head Neck Surg. 2001 Jul;127(7):870-6. — View Citation

Cleeland CS, Mendoza TR, Wang XS, Chou C, Harle MT, Morrissey M, Engstrom MC. Assessing symptom distress in cancer patients: the M.D. Anderson Symptom Inventory. Cancer. 2000 Oct 1;89(7):1634-46. doi: 10.1002/1097-0142(20001001)89:73.0.co;2-v. — View Citation

Eisbruch A, Kim HM, Feng FY, Lyden TH, Haxer MJ, Feng M, Worden FP, Bradford CR, Prince ME, Moyer JS, Wolf GT, Chepeha DB, Ten Haken RK. Chemo-IMRT of oropharyngeal cancer aiming to reduce dysphagia: swallowing organs late complication probabilities and dosimetric correlates. Int J Radiat Oncol Biol Phys. 2011 Nov 1;81(3):e93-9. doi: 10.1016/j.ijrobp.2010.12.067. Epub 2011 May 17. — View Citation

Greco E, Simic T, Ringash J, Tomlinson G, Inamoto Y, Martino R. Dysphagia Treatment for Patients With Head and Neck Cancer Undergoing Radiation Therapy: A Meta-analysis Review. Int J Radiat Oncol Biol Phys. 2018 Jun 1;101(2):421-444. doi: 10.1016/j.ijrobp.2018.01.097. Epub 2018 Feb 6. — View Citation

Hunter KU, Lee OE, Lyden TH, Haxer MJ, Feng FY, Schipper M, Worden F, Prince ME, McLean SA, Wolf GT, Bradford CR, Chepeha DB, Eisbruch A. Aspiration pneumonia after chemo-intensity-modulated radiation therapy of oropharyngeal carcinoma and its clinical and dysphagia-related predictors. Head Neck. 2014 Jan;36(1):120-5. doi: 10.1002/hed.23275. Epub 2013 Jun 1. — View Citation

Hutcheson KA, Bhayani MK, Beadle BM, Gold KA, Shinn EH, Lai SY, Lewin J. Eat and exercise during radiotherapy or chemoradiotherapy for pharyngeal cancers: use it or lose it. JAMA Otolaryngol Head Neck Surg. 2013 Nov;139(11):1127-34. doi: 10.1001/jamaoto.2013.4715. — View Citation

Hutcheson KA, Lewin JS, Barringer DA, Lisec A, Gunn GB, Moore MW, Holsinger FC. Late dysphagia after radiotherapy-based treatment of head and neck cancer. Cancer. 2012 Dec 1;118(23):5793-9. doi: 10.1002/cncr.27631. Epub 2012 May 17. — View Citation

Krisciunas GP, Sokoloff W, Stepas K, Langmore SE. Survey of usual practice: dysphagia therapy in head and neck cancer patients. Dysphagia. 2012 Dec;27(4):538-49. doi: 10.1007/s00455-012-9404-2. Epub 2012 Mar 29. — View Citation

List MA, Mumby P, Haraf D, Siston A, Mick R, MacCracken E, Vokes E. Performance and quality of life outcome in patients completing concomitant chemoradiotherapy protocols for head and neck cancer. Qual Life Res. 1997 Apr;6(3):274-84. doi: 10.1023/a:1026419023481. — View Citation

Martino R, Beaton D, Diamant NE. Using different perspectives to generate items for a new scale measuring medical outcomes of dysphagia (MOD). J Clin Epidemiol. 2009 May;62(5):518-26. doi: 10.1016/j.jclinepi.2008.05.007. Epub 2008 Aug 22. — View Citation

Martino R, Ringash J, Durkin L, Greco E, Huang SH, Xu W, Longo CJ. Feasibility of assessing patient health benefits and incurred costs resulting from early dysphagia intervention during and immediately after chemoradiotherapy for head-and-neck cancer. Curr Oncol. 2017 Dec;24(6):e466-e476. doi: 10.3747/co.24.3543. Epub 2017 Dec 20. — View Citation

McEwen S, Rodriguez AM, Martino R, Poon I, Dunphy C, Rios JN, Ringash J. "I didn't actually know there was such a thing as rehab": survivor, family, and clinician perceptions of rehabilitation following treatment for head and neck cancer. Support Care Cancer. 2016 Apr;24(4):1449-53. doi: 10.1007/s00520-015-3021-1. Epub 2015 Nov 18. — View Citation

MD Anderson Head and Neck Cancer Symptom Working Group. Beyond mean pharyngeal constrictor dose for beam path toxicity in non-target swallowing muscles: Dose-volume correlates of chronic radiation-associated dysphagia (RAD) after oropharyngeal intensity modulated radiotherapy. Radiother Oncol. 2016 Feb;118(2):304-14. doi: 10.1016/j.radonc.2016.01.019. Epub 2016 Feb 17. — View Citation

Mortensen HR, Jensen K, Aksglaede K, Lambertsen K, Eriksen E, Grau C. Prophylactic Swallowing Exercises in Head and Neck Cancer Radiotherapy. Dysphagia. 2015 Jun;30(3):304-14. doi: 10.1007/s00455-015-9600-y. Epub 2015 Feb 19. — View Citation

National Cancer Institute. SEER cancer statistics factsheets: Larynx cancer. http://seer.cancer.gov/statfacts/html/laryn.html. Accessed December 12, 2016.

Nund RL, Ward EC, Scarinci NA, Cartmill B, Kuipers P, Porceddu SV. Carers' experiences of dysphagia in people treated for head and neck cancer: a qualitative study. Dysphagia. 2014 Aug;29(4):450-8. doi: 10.1007/s00455-014-9527-8. Epub 2014 May 21. — View Citation

Ohba S, Yokoyama J, Kojima M, Fujimaki M, Anzai T, Komatsu H, Ikeda K. Significant preservation of swallowing function in chemoradiotherapy for advanced head and neck cancer by prophylactic swallowing exercise. Head Neck. 2016 Apr;38(4):517-21. doi: 10.1002/hed.23913. Epub 2015 Jun 16. — View Citation

Roe JW, Carding PN, Rhys-Evans PH, Newbold KL, Harrington KJ, Nutting CM. Assessment and management of dysphagia in patients with head and neck cancer who receive radiotherapy in the United Kingdom - a web-based survey. Oral Oncol. 2012 Apr;48(4):343-8. doi: 10.1016/j.oraloncology.2011.11.003. Epub 2011 Nov 29. — View Citation

Rosenthal DI, Mendoza TR, Chambers MS, Asper JA, Gning I, Kies MS, Weber RS, Lewin JS, Garden AS, Ang KK, S Wang X, Cleeland CS. Measuring head and neck cancer symptom burden: the development and validation of the M. D. Anderson symptom inventory, head and neck module. Head Neck. 2007 Oct;29(10):923-31. doi: 10.1002/hed.20602. — View Citation

Rubin EB, Buehler AE, Halpern SD. States Worse Than Death Among Hospitalized Patients With Serious Illnesses. JAMA Intern Med. 2016 Oct 1;176(10):1557-1559. doi: 10.1001/jamainternmed.2016.4362. No abstract available. — View Citation

Setton J, Lee NY, Riaz N, Huang SH, Waldron J, O'Sullivan B, Zhang Z, Shi W, Rosenthal DI, Hutcheson KA, Garden AS. A multi-institution pooled analysis of gastrostomy tube dependence in patients with oropharyngeal cancer treated with definitive intensity-modulated radiotherapy. Cancer. 2015 Jan 15;121(2):294-301. doi: 10.1002/cncr.29022. Epub 2014 Oct 6. — View Citation

Shaw SM, Flowers H, O'Sullivan B, Hope A, Liu LW, Martino R. The effect of prophylactic percutaneous endoscopic gastrostomy (PEG) tube placement on swallowing and swallow-related outcomes in patients undergoing radiotherapy for head and neck cancer: a systematic review. Dysphagia. 2015 Apr;30(2):152-75. doi: 10.1007/s00455-014-9592-z. Epub 2015 Mar 4. — View Citation

Siegel RL, Miller KD, Jemal A. Cancer statistics, 2016. CA Cancer J Clin. 2016 Jan-Feb;66(1):7-30. doi: 10.3322/caac.21332. Epub 2016 Jan 7. — View Citation

van der Molen L, van Rossum MA, Rasch CR, Smeele LE, Hilgers FJ. Two-year results of a prospective preventive swallowing rehabilitation trial in patients treated with chemoradiation for advanced head and neck cancer. Eur Arch Otorhinolaryngol. 2014 May;271(5):1257-70. doi: 10.1007/s00405-013-2640-8. Epub 2013 Jul 28. — View Citation

Weinberger PM, Yu Z, Haffty BG, Kowalski D, Harigopal M, Brandsma J, Sasaki C, Joe J, Camp RL, Rimm DL, Psyrri A. Molecular classification identifies a subset of human papillomavirus--associated oropharyngeal cancers with favorable prognosis. J Clin Oncol. 2006 Feb 10;24(5):736-47. doi: 10.1200/JCO.2004.00.3335. Epub 2006 Jan 9. — View Citation

Xu B, Boero IJ, Hwang L, Le QT, Moiseenko V, Sanghvi PR, Cohen EE, Mell LK, Murphy JD. Aspiration pneumonia after concurrent chemoradiotherapy for head and neck cancer. Cancer. 2015 Apr 15;121(8):1303-11. doi: 10.1002/cncr.29207. Epub 2014 Dec 23. — View Citation

* Note: There are 30 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Duration of feeding tube dependence	Effectiveness will be measured based on duration of feeding tube dependency (count of days from end of radiotherapy to last feeding tube use within the 12-month study period)	Baseline - 12 months
Secondary	The MD Anderson Dysphagia Inventory (MDADI)	Measurement of swallowing-related Quality of Life	Baseline, Week 6/7, 3 months, 12 months
Secondary	The MD Anderson Symptom Inventory for Head and Neck Cancer (MDASI-HN)	Measurement of severity or burden of cancer-related symptoms and interference with daily functioning.	Baseline, Week 2, Week 4, Week 6/7, 3 months, 12 months
Secondary	Dynamic Imaging Grade of Swallowing Toxicity (DIGEST)	Videofluoroscopy study score ranging from 0 to 5, where 4 is worst.	Baseline, 3 months, 12 months
Secondary	Pharyngeal Constriction Ratio (PCR)	Videofluoroscopy study score ranging from 0 to 1, where 1 is worst.	Baseline, 3 months, 12 months
Secondary	Penetration-Aspiration Scale (PAS)	Videofluoroscopy study score ranging from 1 to 8, where 8 is worst.	Baseline, 3 months, 12 months
Secondary	Peak esophageal opening	Videofluoroscopy study score ranging from 0 to infinity, where lower value is worse.	Baseline, 3 months, 12 months
Secondary	Performance Status Scale Head and Neck (PSS-HN)	Measurement of swallowing and speech performance	Baseline, Week 2, Week 4, Week 6/7, 3 months, 12 months
Secondary	Medical Outcome of Dysphagia (MOD)	Patient reported symptoms related to health consequences secondary to dysphagia, namely: malnutrition, aspiration pneumonia and mood changes such as depression and anxiety	Baseline, 3 months, 12 months
Secondary	Cancer Behavior Inventory (CBI-V3)	Measurement of self-efficacy strategies for coping with cancer	Baseline, 3 months, 12 months
Secondary	EQ-5D-5L	Measurement of generic quality of life	Baseline, 3 months, 12 months
Secondary	Medical History	Intake details, radiation therapy details, chemotherapy details, tumour status, surgery history, tracheotomy, feeding tube status, feeding tube dependence, concomitant therapies, and complication details.	Baseline, Week 6/7, 3 months, 12 months
Secondary	Pain Medications	All pain medications (including over-the-counter) taken in the past 48 hours	Baseline; Week 6/7, 3 Month, and 12 Months
Secondary	Mouth Opening/Trismus	Measurement of interincisal opening	Baseline; 3 Month and 12 Months
Secondary	Hospitalization/Emergency Department (ED) Presentation	Hospitalization/ED presentation at cancer hospital or any external institutions	Baseline, Week 6/7, 3 months, 12 months